Transcript current trend in maternal to child transmission of hiv

PRE-TEST
• 1.Regargind latest guideline on initiation of ARV start at CD4 of
• A. <200cc/ml
• B.>200cc/ml
• C..<350cc/ml
• D.<500cc/ml
• E. non of the above
• 2.Best ARVs combination for PMTCT should contain at least
• A. AZT
• B. 3TC
• C.TDF
• D.LPV/r
• E. NVP
• 3.Best option advocated by the WHO IS
• A.Option a
• B. Option b
• C.Option c
• D. Option a+
• E. option b+
• 4. Factors associated with MTCH include
• A.low viral load
• B.infections
• C. prolong rupture of membranes
• D.cracked nipples
• E. antepartum haemorrhage
• 5.concerning choice of ARVs for PMTCT
• A.NVP should be avoided in the first trimester
• B.EFZ can be use in the first trimester
• C.NVP is safe in TB/HIV Co infection
• D.AZT IS unsafe throughout pregnancy
• E. EFZ Is teratogenic hence avoid in 1st trimester
CURRENT TREND IN
MANAGEMENT OF
MATERNAL TO CHILD
TRANSMISSION OF HIV
BY DR ZAINAB ABDULAZEEZ UMAR
DEPARTMENT OF FAMILY MEDICINE
SYNOPSIS
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•
•
•
•
•
•
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•
OBJECTIVES
INTRODUCTION
SCOPE OF HIV
MTCT
PMTCT
HAART AND PMTCT
INFANTS FEEDING
CONCLUSION
REFERENCES
LEARNING OBJECTIVES
• To become familiar with factors affecting the transmission of HIV
from mother-to-child
• To become familiar with interventions to prevent the transmission
of HIV from mother-to-child
• To be familiar with current guidelines in managing MTCT
INTRODUCTION
• HIV the aetiological agents of AIDS have been identified as HIV-1
and HIV-2. These viruses belong to the Lentivirus group of
Retroviridae family.
• HIV continues to be a major global public health issue, having
claimed more than 36 million lives so far.
• The Human Immunodeficiency Virus (HIV) targets the immune
system and weakens people's surveillance and defense systems
against infections and some types of cancer.
• As the virus destroys and impairs the function of immune cells, infected
individuals gradually become immunodeficient
• Immunodeficiency results in increased susceptibility to a wide range of
infections and diseases that people with healthy immune systems can fight off
• . The most advanced stage of HIV infection is Acquired Immunodeficiency
Syndrome (AIDS), which can take from 2 to 15 years to develop depending on
the individual
• . AIDS is defined by the development of certain cancers, infections, or other
severe clinical manifestations
• The transmission of HIV from an HIV-positive mother to her child during
pregnancy, labour, delivery or breastfeeding is called mother-to-child
transmission.
• In the absence of any interventions transmission rates range from 15-45%.
• This rate can be reduced to levels below 5% with effective interventions.
• These can be achieved by setting global norms and standards for HIV
prevention, care and treatment of pregnant women, mothers and their
children,
•SCOPE OF HIV
Regional HIV and AIDS statistics and features  2012
25.0 million
Adults and children
newly infected with
HIV
1.6 million
[23.5 million – 26.6 million]
[1.4 million – 1.8 million]
Adults and children
living with HIV
Sub-Saharan Africa
Middle East and North Africa
South and South-East Asia
East Asia
Latin America
Caribbean
Eastern Europe and Central Asia
Western and Central Europe
North America
Oceania
TOTAL
Adult prevalence
(15‒49) [%]
4.7%
1.2 million
[4.4% – 5.0%]
[1.1 million – 1.3 million]
260 000
32 000
0.1%
17 000
[200 000 – 380 000]
[22 000 – 47 000]
[0.1% – 0.2%]
[12 000 – 26 000]
3.9 million
270 000
0.3%
220 000
[2.9 million – 5.2 million]
[160 000 – 440 000]
[0.2% – 0.4%]
[150 000 – 310 000]
880 000
81 000
<0.1%
41 000
[650 000 – 1.2 million]
[34 000 – 160 000]
[<0.1% – 0.1%]
[25 000 – 64 000]
1.5 million
86 000
0.4%
52 000
[1.2 million – 1.9 million]
[57 000 – 150 000]
[0.3% – 0.5%]
[35 000 – 75 000]
250 000
12 000
1.0%
11 000
[220 000 – 280 000]
[9400 – 14 000]
[0.9% – 1.1%]
[9400 – 14 000]
1.3 million
130 000
0.7%
91 000
[1.0 million – 1.7 million]
[89 000 – 190 000]
[0.6% – 1.0%]
[66 000 – 120 000]
860 000
29 000
0.2%
7600
[800 000 – 930 000]
[25 000 – 35 000]
[0.2% – 0.2%]
[6900 – 8300]
1.3 million
48 000
0.5%
20 000
[980 000 – 1.9 million]
[15 000 – 100 000]
[0.4% – 0.8%]
[16 000 – 27 000]
51 000
2100
0.2%
1200
[43 000 – 59 000]
[1500 – 2700]
[0.2% – 0.3%]
[<1000 – 1800]
35.3 million
2.3 million
0.8%
1.6 million
[32.2 million – 38.8 million]
[1.9 million – 2.7 million]
[0.7% - 0.9%]
[1.4 million – 1.9 million]
The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information.
|
Adult & child
deaths due to AIDS
WHO – HIV department | January 19, 2014
with nearly 1 in every 20 adults living with HIV. 69% of all people living with HIV are living in this region.
New HIV infections have fallen by 33% since 2001.
, down from 3.4 New HIV infections among children have
declined by 52% since 2001.
SCOPE IN NIGERIA
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HIV Prevalence in Nigeria is 4.6%
Nigeria now has the second highest number of plwhiv in the world after South Africa.
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Over 90% of HIV infection in children are as a result of MTCT.
•
An estimated 220,000 exposed children born each year.
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Without PMTCT about 88,000(40%) of these are infected.
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With PMTCT about 2% (4,400) infected.
•
Nigeria has 30% of the global burden of MTCT.
SCOPE IN KANO
In 2009 with 372 HIV infected pregnant women detected out of 3470 ANC clients
There were 4922 deliveries out of which 125 were HIV positive, giving a prevalence rate of 2.54%.
the transmission rate from mother to child amongst those who accessed PMTCT services was about 2-3 % .
SCOPE OF HIV/AIDS IN WOMEN
 HIV spreads rapidly, particularly among young women.
 These women are in their most productive and reproductive years.
 There are various factors that make women vulnerable to HIV infection, These factors include:
 Biological factors
 Socio-cultural factors
BIOLOGICAL FACTORS
• Women have larger surface area of the genital mucosa
• Semen infected with HIV contains higher concentrations of virus than vaginal fluid.
• Young women have immature cervix and scanty vaginal secretion hence barrier to
infection is reduced
• Women become more vulnerable again after menopause
• Tearing and bleeding during intercourse further increased predisposition to infection. This
can occur during rough vagina sex, anal sex, dry sex or rape
• Untreated STIs multiplies the risk of HIV infection by 300-400%.
SOCIO-CULTURAL FACTORS
• Economic and societal approved dependency on men
• Rights of women are abused and often violated.
• Condom use by stable partners is often frowned at.
• Cultural practices often expose women to multiple partners e.g polygamy, widow
inheritance, wife hospitality
• Gender inequalities which negatively impacts on and their effect on seeking care and
prevention efforts
• Burden of being the care provider in the home may supercede the need to care for herself
Mother to Child Transmission of HIV
Infection
MOTHER-TO-CHILD TRANSMISSION
MTCT of HIV can occur during:
• Pregnancy
• Labour and delivery
• Breastfeeding
MOTHER-TO-CHILD TRANSMISSION
100 infants born to HIV-infected women who
breastfeed, without any interventions
5–10 infants
infected during
pregnancy
About 15
infants
infected
during labour
and delivery
25–40 infants will be HIV-infected
60 to 75 infants will not
be HIV-infected
5–15 infants
infected during
breast-feeding
Timing of Transmission: Targeting Prevention
(In an Untreated Non-Breastfeeding Population,
Total Transmission Rate is up to 25%)
• Pregnancy ----------
(5 - 10%)
• Delivery -------
(10 -15%)
• Breastfeeding -----
(10 - 15%)
RISK FACTORS FOR MTCT
Pregnancy
Labour and Delivery
Breastfeeding
•High maternal viral load
•High maternal viral load
•High maternal viral load
•Infection
•Duration
•STIs
•Prolonged rupture of
membranes
•Malnutrition
•Invasive delivery procedures
•Haemorrhage
•Chorioamnionitis
•Early mixed feeding
•Breast fissures, infections
•Poor maternal nutrition
•Oral disease in infant
PMTCT
Prevention
Of
Mother
To
Child
Transmission
• Best practice for antenatal, intrapartum and postpartum care of
the HIV-positive mother to reduce mother-to-child transmission
ELEMENTS OF A SUCCESSFUL PROGRAMME FOR PREVENTION OF HIV INFECTION
IN INFANTS AND YOUNG CHILDREN
• Element 1 Primary prevention of HIV infections
• Element 2 Prevention of unintended pregnancies among women infected with HIV
• Element 3 Prevention of HIV transmission from women infected with HIV to their infants
• Element 4 Provision of treatment, care and support to women infected with HIV, their infants and their families
ELEMENT 1: PREVENTION OF
PRIMARY HIV INFECTION
ABCs of primary HIV prevention for parents-to-be:
A = Abstain
B = Be faithful to one HIV-uninfected partner
C = Condom use – use condoms consistently and correctly
Adapt approach to local culture and target groups at risk
ELEMENT 2: PREVENTION OF
UNINTENDED PREGNANCIES
AMONG WOMEN INFECTED WITH HIV
• Access to counselling and referral for family planning
• Safe, consistent, effective contraception
ELEMENT 3: PREVENTION OF HIV
TRANSMISSION FROM WOMEN
INFECTED WITH HIV TO THEIR INFANTS
Core Interventions
•
HIV testing and counselling
•
Antiretrovirals
•
Safer delivery practices
•
Safer infant-feeding practices
Combination interventions can reduce the MTCT rate to as low as 2% in
the absence of breastfeeding.
ELEMENT 4: TREATMENT,
CARE AND SUPPORT FOR WOMEN
INFECTED WITH HIV AND THEIR FAMILIES
•
Prevention and treatment of OIs
•
ARV treatment
•
Treatment of symptoms
•
Palliative care
•
Nutritional support
•
Reproductive healthcare
•
Psychosocial and community support
SPECIFIC INTERVENTIONS TO REDUCE MOTHER-TOCHILD TRANSMISSION
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HIV testing and coucelling in pregnancy
Antenatal care
Antiretroviral agents
Obstetric interventions
• Avoid amniotomy
• Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood
sampling
• Restrict episiotomy
• Elective cesarean section
• Remember infection prevention practices
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• Newborn feeding: Breast milk vs. formula
TESTING AND COUNSELING FOR PMTCT
• Offered in the following settings
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•
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Antenatal care
Labour and delivery
Postnatal
Family planning and other services
Information offered are the following:
• HIV Infection and mode of transmission
• Safer sex practices
• Prevention and treatment of sexually transmitted infections (STIs)
• Prevention of HIV in infants and young children including interventions for PMTCT
• HIV testing, post-test counseling, and follow-up services
• INFORMATIO OFFERED TO HIV +VES (POST TEST)
• Antiretroviral treatment/prophylaxis
• Infant-feeding counseling and support
•
Information and counseling on family planning
•
Receive education on the importance of delivering in a setting where universal precautions and
safer obstetric practices are implemented.
• Secure early access to HIV treatment, care and support services.
• Receive information and counseling on the prevention of HIV transmission to others.
• Receive follow-up and ongoing health care for themselves and their HIV-exposed infants.
• Disclose their results to partners and family members.
LAB. TESTING FOR HIV INFECTIONS
• Detectable components or products of viral infection for diagnosis
• Antibodies• Rapid tests
• ELISA(reactive/non-reactive),
• Western blot (positive, negative, Indeterminate.)
• Antigen- antigen P24
• Nucleic acid- polymerase chain reaction
• Whole(viable)virus- viral culture
LABORATORY TESTING(4)
CD4 lymphocyte count.
• Normal laboratory ranges 500-1400/mm.
• Most useful for assessing immune function.
• Degree of immuno-suppression determines staging of HIV infection, recommendations for ARV and prophylaxis
against OIs.
Viral Load estimation
•
•
goal is to reduce viral load to undetectable (<400 copies/mL)
OTHER TESTS: BASELINE LABS TESTS
• FBC (anemia with ZDU)
• LFTs (mitochondrial disease with NRTI, elevated ALT w/ NNRTI and PI)
• amylase (pancreatitis with NRTI)
• early 1-hr OGT (GDM with PI)
• creatinine
• Hep B & C, CMV, toxo
ANTENATAL CARE
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Most HIV-infected women will be asymptomatic
Watch for signs/symptoms of AIDS and pregnancy-related complications
Treat STDs and other coinfections
Counsel against unprotected intercourse
Avoid invasive procedures and external cephalic version
Give antiretroviral agents
Counsel about nutrition
HIV and Pregnancy
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Clinical Stage 1
Clinical Stage 2
Asymptomatic
Mild Disease
No symptoms or only:

Persistent generalized
lymphadenopathy
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


Weight loss 5-10%**
Sores or cracks around
lips (angular cheilitis)
Itching rash (seborrhoea
or prurigo)
Herpes zoster
Recurrent
upper
respiratory
infections
such as sinusitis or otitis
Stage 3 Advanced Disease
Stage 4 Severe Disease (AIDS)
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

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Weight loss > 10%**
Oral thrush (or hairy
leukoplakia)
More than 1 month:
Diarrhoea or
Unexplained fever
Severe bacterial infections
(pneumonia,
muscle
infection, etc)
Pulmonary TB
TB lymphadenopathy
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
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HIV wasting syndrome
Oesophageal thrush
More than 1 month:
Herpes simplex ulcerations
Recurrent severe pneumonia
within 6 months
Lymphoma*
Kaposi sarcoma
Invasive cervical cancer*
CMV retinitis*
Pneumocystis pneumonia
Extrapulmonary TB*
Toxoplasma*
Cryptococcal meningitis*
Visceral leishmaniasis*
If CD4 < 350 Cotrimoxazole &
INH prophylaxis
If CD4 < 350 Cotrimoxazole
& INH prophylaxis
Cotrimoxazole & INH
prophylaxis
Cotrimoxazole & INH
prophylaxis
Consider ART if CD4 < 350
Consider ART if CD4 < 350
ART
ART
 Strict adherence critical but a challenge in pregnancy
 ARVs have side effects that need clinical and lab monitoring
 Beware of drug interactions
 Resistance may develop if adherence is not excellent or if drug
interactions affect drug levels, resistance may occur
 Resistance may be spread to baby and to partner
With excellent adherence and monitoring, risks of ARV are minimised
and benefits are maximised
HIV IN PREGNANCY: DRUG TREATMENT
• The goal in pregnancy is to reduce viral load to undetectable to minimize
perinatal transmission.
• However, the woman should be counselled and willing to adhere to the
regimen
• She should be counselled on the risks and benefits of the ARVs
Evolution of the efficacy of the ARV prophylaxis:
1994-2004
% Transmission
Transmission Rate (%)
35
30
25
20
15
10
5
0
None & None no NVP &
BF
BF
BF
AZT
AZT
36wks & 36wks
no BF
BF
AZT
28wks
no BF
HAART HAART
AZT
28wks + no BF + C-S no
BF
NVP no
BF
THE DIFFERENT ANTIRETROVIRAL DRUGS
NRTI
Nucleoside
transcriptase
(NsRTI)
NNRTI
reverse Nucleotide
inhibitors transcriptase
(NtRTI)
zidovudine (AZT)
lamivudine (3TC)
abacavir (ABC)
emtricitabine
stavudine (d4T)
reverse Non-nucleoside reverse Protease Inhibitors (PI)
inhibitor transcriptase inhibitors
(NNRTI)
tenofovir
disoproxil nevirapine (NVP)
fumarate (TDF)
efavirenz (EFV)
(FTC)
PI
saquinavir (SQV) ritonavir
(RTV), as booster*
indinavir (IDV) nelfinavir
(NFV) lopinavir (LPV)
OTHERS
Fusion Inhibitor
 Enfuvirtide (ENF, T-20)
CCR5 Antagonist
 Maraviroc (MVC)
Integrase Inhibitor
 Raltegravir (RAL)
FIRST - LINE AND SECOND-LINE REGIMEN
• A first-line regimen is a combination of drugs that will be used in a patient who has no prior ART experience. This
means that the patient has never taken ARV drugs before.
• Most commonly, a first-line regimen will consist of two NsRTI's and one NNRTI.
• Many patients will eventually develop failure of therapy: the first-line therapy will not be effective anymore
(often because the drugs were not taken correctly). In that case, the doctor may decide to switch to a second-line
regimen.
• Usually, the second-line regimen will consist of 2 NRTI + 1 PI.
ART INITIATION
ART should be initiated in all pregnant women based on the following
criteria.
•
CD4 count of less than or equal to 350 irrespective of WHO clinical
staging.
•
WHO stages III and IV irrespective of CD4 cell count.
•
Nigerian guideline Recognizes pregnancy as an indication for prophylactic
ART irrespective of CD4 count, viral loads or clinical staging
Women With CD4 Count
above 350 Cells/mm3
Women With CD4 Count
beloW 350 Cells/mm3
ChilD receives
option a
During pregnancy: AZT
Triple ARVs started as
starting as early as 14
soon as diagnosed and
weeks of pregnancy At
continued for life
delivery: single-dose NVP
and first dose of AZT/3TC
After delivery: daily
AZT/3TC through 7 days
postpartum
Daily prophylaxis (NVP)
from birth until 1 week
after all breastfeeding
has finished; or, if not
breastfeeding or if
mother is on treatment,
through age 4–6 week
Option b
Triple ARVs starting as
early as 14 weeks of
pregnancy continued
through childbirth (if not
breastfeeding) or until 1
week after all
breastfeeding has
finished
Daily prophylaxis (NVP or
AZT) from birth through
age 4–6 weeks
regardless of infant
feeding method
Option b+
Triple ARVs started as soon as diagnosed and
continued for life
Advantages of Option B+
• Further simplification of regimen and service delivery (One regimen See
•
•
•
•
•
and Treat)
Harmonization with ART programmes (TDF + 3TC or FTC + EFV as first
line regardless of CD4 count)
Protection against mother-to-child transmission in future pregnancies
Continuing prevention benefit against sexual transmission to
serodiscordant partners
Avoiding stopping and starting of ARV drugs
HBV Co-infection therapy
CHOICE OF ARV”S IN PREGNANCY
 Combination regimens, usually including 2 NRTIs with either a
NNRTI or 1 or more protease inhibitors (PIs) are recommended
 AZT + 3TC + EFV/NVP
 AZT + 3TC (or FTC) + EFV/NVP
 AZT + 3TC + LPV/r
 AZT + 3TC + ABC
 TDF + 3TC (or FTC) + EFV/NVP
NOTE
 Nevirapine is avoided in women with CD4 count >250.
 EFV is avoided in the first trimester
• Any pregnancy regimen should include ZDT unless contraindicated
• Combination HAART (3 drugs) is associated with vertical transmission rates of
<2% and is considered standard of care (regardless of VL or CD4+)
• Safety of HAART in pregnancy is reassuring
• Continue drugs during labor
NEW RECOMMENDATIONS IN WHO ART GUIDELINES (2013)
• • Earlier initiation of ART (CD4 ≤ 500)
• • 1) Immediate ART for children below 5 years
• • 2) Harmonization of ART across populations (e.g., adults and pregnant
women, B/B+) and age groups
• • 3) Simplified, fewer, and less toxic 1st line regimens (TDF/3TC/EFV)
• • 4) Improved patient monitoring to support adherence and detect failure
(increased use of VL)
• • 5) Recommend task shifting, decentralization, and integration
TARGETS FOR E-MTCT
CLINICAL SCENARIO 1:PREGNANT WOMAN HAS RECEIVED
ARV MEDICATION IN THE PAST BUT IS NOT CURRENTLY ON
ANY MEDICATION
• the choice of regimen may vary according to the history of prior
use, the indication for stopping treatment in the past, gestational
age, and resistance testing
• if there is no resistance to the drugs, ARV(HAART) can be used
again, but avoid drugs with teratogenic potential or adverse
maternal effects.
• Commence ARVS as soon as possible(AZT+3TC+NVP/EFZ) OR TDF
CLINICAL SCENARIO II:PATIENT WHO IS ON A HAART
REGIMEN PRESENTS FOR PRENATAL CARE
•
continuing her treatment during the first trimester is reasonable,
• Zidovudine should be a component of the regimen whenever
possible
• provided that care is taken to avoid medications that are
contraindicated in early pregnancy
CLINICAL SCENARIO III:ARV NAÏVE HIV-INFECTED
PREGNANT WOMAN
• 1.In facility with capacity to provide and monitor triple ARV
• HAART should be started as soon as possible, including during the
first trimester.
• Infant:dly NVP irrespective of feeding option
CONT IIIB
• 2.In facility with limited capacity to provide &
monitor triple ARVS
The following ARV prophylactic regimen is
recommended:
 Zidovudine from 14 weeks gestation.
Sd NVP at onset of labour
AZT+3TC during labour and delivery
AZT+3TC for 7 days post partum
PROPHYLAXIS FOR PMTCT
CLINICAL SETTING IIIB :
THE INFANT
• A For breastfeeding infants:
 Commence daily NVP and continue until one week after cessation of all breastfeeding.
• B For non-Breastfeeding infants:
 Give daily NVP for 6 weeks only
CLINICAL SCENARIO IV:HIV +VE DIAGNOSED IN LABOR
1. For facilities with capacity to provide and monitor Triple ARV medication:
Mother
 Commence triple ARV prophylaxis during labour and continue thru bf
2. For facilities with limited capacity (on–site or by linkage) to provide and monitor triple ARV
medication.
Mother:
• Intrapartum:
 sdNVP + ZDV + 3TC as soon as diagnosis is made in labour.
• Post partum:
 ZDV + 3TC for 7 days
• Determine if mother is eligible (within 5 days of delivery) for HAART
Infant:
• Mother breastfeeding not commenced on HAART:
 Give daily NVP to infants from birth until one week after cessation of all
breastfeeding
• Mother breastfeeding (eventually commenced on HAART)
 Give daily NVP to infants from birth and continue until six weeks after maternal
commencement of HAART
• Mother not breastfeeding:
 Give daily NVP to infants from birth until 6 weeks of age.
CLINICAL SETTING V
RECOMMENDATIONS FOR PREGNANT HIV-SEROPOSITIVE
MOTHERS WHO PRESENT AFTER DELIVERY
If mother chooses to breastfeed, recommend
HAART (follow guidelines for HAART eligible
mothers)
If mother chooses to formula feed, determine if
mother is eligible for HAART for her own disease,
Infant :give sdnvp and then for 6 wks
CLINICAL SETTING VI:
HIV-INFECTED WOMAN WITH ACTIVE TB
• Delay ARV treatment until second trimester, if possible.
Treatment regimens: These are in decreasing order of preference
• If treatment is initiated in second trimester
 EFV (800mg) + 2NRTIs
 ZDV + 3TC + Abacavir
 2 NRTIs + Ritonavir-boosted PI* (Saquinavir/r or Lopinavir/r)
 ZDV + 3TC + Tenofovir
Change rifampin to low dose rifabutin
INFANTS:Prophylactic INH from birth (5mg/Kg once daily) until six (6) months of age
WHO PROGRAMMATIC UPDATE APRIL 2012
• Option B+:
– Triple ARV drugs to all HIV-infected pregnant women beginning
in the antenatal clinic setting and continuing this therapy for all
of these women for life.
• Now being considered by the PMTCT Task Team
NATIONAL RECOMMENDATIONS 2010
INFANTS
• HIV+ Mothers ( whose infants are HIV uninfected or of unknown HIV status) should exclusively
breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods
thereafter, and continue breastfeeding for the first 12 months of life.
Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.
When HIV-infected mothers decide to stop breastfeeding (at any time) they should do so gradually within one
month
: MONITORING OF THERAPY
• Check viral load, CD4+, LFTs, FBC every trimester
• Consider change of therapy if viral load still detectable in 3-6
months
• Exclude adherence problems
• Is she taking her meds??
• Baseline ARV resistance testing
• HAART naïve (new) cases
• HAART re-starts
• if suboptimal viral suppression
CARE IN LABOUR AND DELIVERY
•
•
•
•
•
AVOID ARM/FETAL SCALP PROCEDURES/ECV
UNIVERSAL PRECAUTIONS SHOULD BE APPLIED
AVOID ROUTINE EPISIOTOMY
FORCEPS PREFERABLE TO VACUUM
ELECTIVE C/S BENEFICIAL
• Elective Caesarean section (C/S) reduces the risk of MTCT
by at least 50% compare with vaginal delivery
• Following delivery, avoid milking the cord.
• The baby should be thoroughly dried, and any remaining maternal
blood and amniotic fluid should be removed.
• Vigorous suctioning of the infant’s mouth and pharynx should be
avoided
• Vaginal cleansing using disinfectants such as chlorhexidine where
SVD is anticipated.
• Use partogram to monitor labour progress.
• Determine mother’s feeding choice
INFANT FEEDING OPTIONS
Allow mother to take decision by her self after counselling.
Exclusive Breast feeding
1 Support mother, put baby to breast immediately,
exclusive, proper position & attachment, feed on demand
2 Modification of BF
a Early cessation- stop by 6 mths.
b Expressing & heat treating BM.
c Wet nursing- not advisable.
• EXCLUSIVE FORMULAR FEEDING
A- acceptable.
F- feasible.
A- affordable.
S- sustainable.
S- safe.
Types –commercial infant formula & home made modified
animal milk.
COMPREHENSIVE POSTPARTUM CARE AND SUPPORT

Components of comprehensive care include the following medical and supportive
care services:
•
•
•
•
•
•
Primary, obstetric, paediatric and HIV specialty care
Family planning services
Immunization/prophylaxis against OIs
Mental health services
Substance-abuse treatment
Coordination of care through case management for the woman, her children, and other
family members.





Support services should include
case management
childcare, respite care,
assistance with basic life needs (eg. housing, food,
and transportation), and legal and advocacy
services.
Continuity of antiretroviral treatment must be
ensured.
ROLE OF FAMILY PHYSICIAN
• HIV IS ONE DISEASE THAT ALLOWS THE FAMILY PHYSICIAN TO PRACTICE WITH ALL HIS SKILLS
-COUNSELING\EDUCATING
-PERSONALISED CARE
-CONTINOUS CARE
-FAMILY CARE
-TEAM WORK\REFERRAL ETC
CONCLUSION
 PMTCT is a success story in HIV prevention.
 A proper understanding of the basic principles of HIV and ARV use
is all that is necessary to achieve this success.
 The implementation of the core PMTCT interventions based on
these principles will reduce MTCT from 40% to about 2%.
REFERENCES
• British HIV Association guidelines for the management of HIV infection in pregnant women 2012
• National guidelines on PMTCT 2010
• National guidelines on PMTCT 2012
• H Galadanci et al Outcome of deliveries among HIV +ve mothers at AKTH – NJM 2006.
• Infant feeding in HIV – generic training manual.
•
Expanding and Simplifying Treatment for Pregnant Women Living with HIV
• HIV in pregnancy www.medscape.com/hiv in pregnancy
• WHO Guideline on PMTCT
• AITT option b+ Toolkit 2013 expanding and simplifying treatment for pregnant women www.emtct.iatt.org
• V Mangiaterra WHO: Global plan to eliminate MTCT of HIV 2013